Provider Demographics
NPI:1003309311
Name:BALLARD, JAMES KEITH JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:KEITH
Last Name:BALLARD
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 BROOKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2640
Mailing Address - Country:US
Mailing Address - Phone:601-823-3200
Mailing Address - Fax:
Practice Address - Street 1:706 BROOKWAY BLVD
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2640
Practice Address - Country:US
Practice Address - Phone:601-823-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4005-181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice